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Totally Endoscopic Aortic Valve Replacement With a Trifecta GT Bovine Pericardial Valve

Tuesday, August 20, 2019

Pitsis A, Tsotsolis N, Nikoloudakis N, Kelpis T, Economopoulos V, Keremidis I. Totally Endoscopic Aortic Valve Replacement With a Trifecta GT Bovine Pericardial Valve. August 2019. doi:10.25373/ctsnet.9587900.

The authors present a video showing their technique of totally endoscopic aortic valve replacement with a bovine pericardial valve (Trifecta GT, Abbott), performed for an 81-year-old patient with severe aortic stenosis and moderate aortic regurgitation. The patient was heavily symptomatic in class III and had a EuroSCORE II of 2.36. The patient was positioned supine on the operating table, with his right shoulder elevated by 30 degrees. Double lumen ventilation was also used.

The operation was performed through a 3 cm working incision in the second intercostal space parasternally, with two 10 mm ports in the second and fifth intercostal spaces in the anterior axillary line. The extra small Alexis wound protector was used in the working incision. A 3D 30-degree Karl Storz endoscope was inserted in the second intercostal port and the whole of the procedure was done under stereoscopic vision. The fifth intercostal port was used for the right-hand instruments during the opening of the pericardium and for the left atrial vent while the aorta was cross-clamped.

Three pericardial retraction sutures where used to retract the pericardium and the heart towards the endoscope (the sutures were externalized in the first, third, and seventh intercostal spaces in the middle axillary line).

The Chitwood cross-clamp was inserted through a separate hole in the first intercostal space, anterior and superior to the endoscope. On femoro-femoral cardiopulmonary bypass, the aorta was cross-clamped and Custodiol cardioplegia was used to arrest the heart. Half of the dose was given in the aortic root and the other half directly in the coronary ostia (due to the aortic regurgitation), after performing a transverse aortotomy 3 cm above the right coronary ostium. The heavily calcified valve was excised using long-shafted instruments, and the annulus was sized. A 23 mm Trifecta GT (Abbott) bovine pericardial prosthesis was inserted using 2/0 Ethibond sutures secured with the COR-KNOT® automated suture-fastening device. In order to facilitate the placement of the annular sutures, the authors used a self-expanded iron net to increase the volume of the aortic root.

The aortotomy was closed in two layers, the heart was de-aired, and the cross-clamp was removed. Postoperative transesophageal echocardiography confirmed a normally functioning prosthesis. The patient was extubated a couple of hours later and had an uneventful recovery.

Additional Resources

  1. Pitsis A, Tsotsolis N, Nikoloudakis N, et al. Totally endoscopic redo tricuspid valve repair. CTSNet. June 2019. doi: 10.25373/ctsnet.8199260.
  2. Pitsis A, Nikoloudakis N, Tsotsolis N, et al. Totally endoscopic bileaflet mitral valve repair with preformed chordae loops. CTSNet. March 2019. doi: 10.25373/ctsnet.7837853.

Dr Antonios Pitsis serves as a Proctor for Abbott.


Innovative procedure with excellent outcome! It would be useful to share with us some tips compared with the mitral procedure that you have mastered over these years. Certainly this technique could serve a larger pool of patient-candidates as opposed to the mitral ones, as the aortic valve pathology prevails that of the mitral valve. Additionally it is a timely technique now that the TAVI is recruiting low risk patients. Keep up the good work Antonis!!
I would to thank Dr. Stavridis for his kind and constructive comments. The main difference between the aortic and the mitral endoscopic procedures is that the ascending aorta is quite close to the sternum and so there is limited space underneath the sternum to insert the endoscopic camera and instruments and to work. Therefore, we have to generate more space. In order to do so we place the endoscope in a more lateral position (right anterior axillary line) and we retract the pericardium towards the axilla. Also, we use the second endoscopic port for the right hand instruments until we go on CPB and decompress the heart, at which time the space to work on the ascending aorta has been created. Sometimes it is useful to retract the right atrial appendage towards the diaphragm with another stay suture. Additionally, compared to the mitral procedures, we have to place the Chitwood clamp in a higher position and the cardioplegia cannula higher and more anteriorly in the ascending aorta . Upon opening the transverse aortotomy we have to place another stay suture and retract the distal part of the aortotomy incision upwards, towards the innominate vein - SVC junction. And finally, it is important to place the net expander inside the aortic root in order to increase its volume. Then you have achieved an excellent exposure of the aortic valve and you can perform repairs or replacement with tissue or mechanical prostheses. I agree with you George that this is a procedure that could serve a large pool of patients. Thank you once more!
I would like to thank Dr. Peeler for the question. The XC time is in the region of 60 to 90 minutes depending on patients anatomy and the CPB time 100 to 120 minutes. Needles to say the times are dropping as we built up our experience. This is certainly a procedure with a steep learning curve. Despite the extended XC and CPB times compared to the sternotomy or hemisternotomy, the patients tend to bleed a lot less (200 mls until the drains are removed), they are discharged a couple of days earlier and the huge difference is when you see them in the follow up clinic a month later where they are fully functional compared to the sternotomy patients who need another month or two. Finally, as Dr. Peeler is a Paediatric and Adult Congenital Cardiac Surgeon, I would like to add that we have treated totally endoscopically with a similar approach subaortic stenosis, and many ASDs (secundums, sinus venosus and primums) .

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